The Care Quality Commission
  • Mental Health
  • Independent mental health service

Archived: Cambian - The Willows

Overall: Good read more about inspection ratings

Fitton End Road, Gorefield, Wisbech, Cambridgeshire, PE13 4NQ (01945) 871491

Provided and run by:
Cygnet Behavioural Health Limited

Important: The provider of this service changed. See old profile

All Inspections

8 March 2016

During a routine inspection

We rated Cambian – The Willows as good because:

  • Risk assessment and risk management plans were of good quality, consistent and reviewed regularly.
  • Staff had a good understanding of the different levels of observation necessary to keep patients safe. They followed the hospital’s policy and documented observations appropriately.
  • The service complied with local safeguarding children board procedures and appropriate national guidance. Staff were knowledgeable about safeguarding patients from abuse and had access to safeguarding leads for further guidance.
  • Staff completed a comprehensive assessment of the patients’ needs in a timely manner. They held formulation meetings with families and other agencies to develop up to date, personalised recovery focused care plans.
  • The service used best practice guidance to improve patients’ self-esteem and confidence and promoted the use of diversionary activities.
  • The service manager and clinical lead supported staff, who received regular clinical and managerial supervision. Staff had an annual appraisal of their work performance and were able to contribute with suggestions.
  • The multi-disciplinary team (MDT) introduced a ward round book. This encouraged patients to write down what they wanted to discuss but did not feel confident to say in person.
  • Staff treated patients with kindness, respect and compassion. They participated in activities and interacted at an appropriate level.
  • The service had a clear admissions policy, taking into account the current mix of patients before accepting new admissions, to prevent the recovery of existing patients from being compromised. Staff devised a weekly activity plan offering a range of therapeutic pursuits, with activities provided by external organisations. These included local animal centres and specialised art therapy centres.
  • The service provided meals that met patients’ specific dietary requirements. The catering team took into account culture, individual preferences and allergies when producing menus and provided clear information about the ingredients used in each dish.
  • The service had a clear organisational governance structure and used key performance indicators to monitor service performance.

However:

  • The provider’s Mental Health Act (MHA) policy was not up to date following changes made to the code of practice in April 2015.
  • Staff compliance with mandatory MHA and Mental Capacity Act (MCA) training was 55%. We were not assured this training included the MHA revised code of practice.
  • The service was not always able to accommodate external activities on a one to one basis.
  • Action plans developed from feedback obtained from patients’ contained actions carried over from one plan to another with no end date.

12 August 2013

During an inspection in response to concerns

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

Following our inspection of 04 July 2013 we found that the provider was not meeting all the essential standards. We conducted this inspection of 12 August 2013 due to on-going concerns about the quality of care being provided at Cambian-The Willows. The provider submitted an action plan to us for our 04 July 2013 inspection and told us they would be compliant with the required standard by 30 September 2013. We also reviewed the providers action plan following our 04 July 2013 and 12 August 2013 inspections.

During our inspection of 12 August 2013 we found that the provider had made improvements to patients' care. Records we reviewed evidenced to us that patients' care was regularly reviewed and ensured that they were always cared for based upon the most up-to-date care and support information.

Patients we spoke with told us they liked some of the staff at Cambian-The Willows and that they felt supported and safe. Safeguarding training records evidenced that the majority of staff had completed safeguarding of children and vulnerable adults training.

The provider had also made improvements with their quality assurance system to collected untoward incident records to inform patient care.

4 July 2013

During an inspection looking at part of the service

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

We visited the service on 4 July 2013 and found that the provider had failed to fully comply with the warning notice we issued the notice on 20 March 2013 following our inspection dated 11 February 2013. We are considering further enforcement action.

We found that reliable arrangements were not always in place to safely support the planning and delivery of all the treatment and care being provided. Also, the arrangements to obtain consent for the administration of medication were not robust.

The quality assurance system was not robust. This had resulted in shortfalls not being identified in the delivery of treatment and care, in the obtaining of consent and in the management of untoward incidents.

These problems reduced the reassurance patients could have that they would receive all of the treatment and care they needed in a safe and reliable way.

11 February 2013

During an inspection looking at part of the service

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

Patients were involved as much or as little as they wanted to be with their care treatment and support. Patients were able to choose what they wanted to do and how much or how little support they needed, where this was safe to do so.

Patients who lacked the mental capacity to consent had their consent to treatment determined through best interest meetings. Records we reviewed showed us that patients' valid consent to manage their finances had been obtained.

Only one out of the four care plans that we reviewed contained information that would allow any member of staff to care for that patient. Guidance contained in patients' plans of care and on how staff supported patients was limited.

We reviewed the service's safeguarding of young people and vulnerable adults policy and found that it was relevant and up-to-date.

We reviewed patients' medicines administration and found that there were few gaps in the records.

Patients who had been discharged from their detention under the Mental Health Act 1983 had not had their risk assessments updated. We could not be sure that patients were cared for with up-to-date care and support information.

26 November 2012

During a routine inspection

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

We could not be sure that people were involved in the planning of their care as was reasonably practicable. People's care plans contained plenty of information but it was not possible to determine what was and wasn't relevant. Risk assessment had not all been completed fully so we could be sure that staff had accurate and up-to-date information.

We found that the medicines administration records were not always completed correctly and that there were omissions in the records.

Cambian - The Willows building and general decor was in a good state of repair and work had recently been undertaken to refurbish and improve the security of the location.

Visiting health care professionals and people who use the service told us that they felt that there were sufficient staff to meet their needs. The staff rosters showed to us that the provider had sufficient staff to manage and run the service in a safe manner.

The provider had sought to obtain the views and comments from people who use the service, relatives and representatives and health care professionals with a view to improving the quality of service provided.